The November elections are nearing, and early voting begins as soon as September 23 in some states. As you consider how to cast your vote, avoid letting the federal general election politics suck all the oxygen from your electoral choices closer to home, at more local levels. Many reproductive health policies and regulations are decided at state levels. Unfortunately, many of those policies and regulations have served to roll back rights and diminish access to reproductive health resources. However, there has been some movement forward, toward increasing access to contraceptives, with provisions for allowing insurers to dispense 12-month supplies of contraceptives and pharmacists to prescribe hormonal contraceptives. (See the figure from Kaiser Family Foundation at the end of the text.)[1]

Allowing a 12-month contraceptive supply

The CDC’s Selected Practice Recommendations for Contraceptive Use (SPR) states that the more pill packs provided, up to 13 cycles, the higher the continuation rates.[2] Studies additionally indicate that a 12-month contraceptive supply dispensed at one time can reduce the risk of unintended pregnancy by as much as 30%.[3] Thus the SPR recommends that women be prescribed up to a 1-year supply upon initial and return visits, thereby allowing a women to obtain COCs in the amount she needs at the time she needs them.

Users have long struggled to make the fluidity of life and its demands fit neatly into a rigid calendar of contraceptive supply. However, as of today, eight states (Hawaii, Illinois, Maryland, Minnesota, New York, Oregon, Vermont, and Washington) and the District of Columbia have approved legislation for pharmacists to dispense and insurers to reimburse for multiple pill packs at one time: generally a year’s supply (6 months in Maryland). Eleven states (Alaska, California, Florida, Iowa, Michigan, New Jersey, Virginia, and Wisconsin) have introduced similar legislation. Where does your state stand? (See the map below).

Pharmacist-prescribed hormonal methods

Allowing pharmacists to prescribe hormonal contraceptives is another policy strategy to increase contraceptive access. Earlier this year, the American Congress of Obstetricians and gynecologists published a statement, which supported over-the-counter contraceptive pills in preference to pharmacist-prescription, that said, “Requiring a pharmacist to prescribe and dispense oral contraceptives only replaces one barrier — a physician’s prescription — with another.”[4] Though not a ringing endorsement, the statement followed a 2012 ACOG committee opinion indicating that “Pharmacists successfully used checklists to identify women without contraindications to OCs according to the World Health Organization’s Medical Eligibility Criteria for Contraceptive Use; blood pressure and body mass index also were measured… Continuation of use through 12 months was fairly high…”[5]

In hopes of making access to hormonal contraceptives easier and simpler for women, lawmakers in 12 states have introduced bills to allow pharmacist-prescribed hormonal contraceptives, according to the Guttmacher Institute.[6] California became the first state to pass such a bill, in late 2015, followed by Oregon in January 2016 and Tennessee in March. Experience from California suggests that many pharmacies are still trying to work out a strategy for providing the service. NPR reports that “Most pharmacists said they still needed to undergo the state-mandated training and that their stores were in the process of figuring out what the service would look like.”[7] Pharmacists who choose to provide the service will need special training in providing hormonal contraception. And outside Oregon, the finances aren’t clear because most insurance providers do not pay for a pharmacist’s time to screen women, consult resources such as the U.S. Medical Eligibility Criteria, and counsel and educate clients about their contraceptive methods. That means that patients must pay for the service or the pharmacist must deliver the service for free. (In Oregon, the state Medicaid program reimburses pharmacists $35 for their time, NPR reports.)

What is entailed in pharmacist-prescribed contraceptive services? Below are illustrative excerpts from the California and Oregon bills:

Procedure: When a patient requests self-administered hormonal contraception, the pharmacist shall complete the following steps:

(A) Ask the patient to use and complete the self-screening tool;

(B) Review the self-screening answers and clarify responses if needed;

(C) Measure and record the patient’s seated blood pressure if combined hormonal contraceptives are requested or recommended.

(D) Before furnishing self-administered hormonal contraception, the pharmacist shall ensure that the patient is appropriately trained in administration of the requested or recommended contraceptive medication.

(E) When a self-administered hormonal contraceptive is furnished, the patient shall be provided with appropriate counseling and information on the product furnished, including:

(5) Self-Screening Tool: The pharmacist shall provide the patient with a self-screening tool containing the list of questions specified in this protocol. The patient shall complete the self-screening tool, and the pharmacist shall use the answers to screen for all Category 3 and 4 conditions and characteristics for self-administered hormonal contraception from the current United States Medical Eligibility Criteria for Contraceptive Use (USMEC) developed by the federal Center for Disease Control and Prevention (CDC). The patient shall complete the self-screening tool annually, or whenever the patient indicates a major health change.

(D) Provide the patient with a written record of the hormonal contraceptive patch or self-administered oral hormonal contraceptive prescribed and dispensed and advise the patient to consult with a primary care practitioner or women’s health care practitioner; and

(E) Dispense the hormonal contraceptive patch or self-administered oral hormonal contraceptive to the patient as soon as practicable after the pharmacist issues the prescription.

…

The rules adopted under this subsection must prohibit a pharmacist from:

(A) Requiring a patient to schedule an appointment with the pharmacist for the prescribing or dispensing of a hormonal contraceptive patch or self-administered oral hormonal contraceptive; and

(B) Prescribing and dispensing a hormonal contraceptive patch or self-administered oral hormonal contraceptive to a patient who does not have evidence of a clinical visit for women’s health within the three years immediately following the initial prescription and dispensation of a hormonal contraceptive patch or self-administered oral hormonal contraceptive by a pharmacist to the patient.

[7] O’Mara K. Law allows women to obtain birth control without prescription, but few pharmacies offer service. KQED NPR State of Health blog, May 16, 2016. At https://ww2.kqed.org/stateofhealth/2016/05/19/law-allows-women-to-obtain-birth-control-without-prescription-but-few-pharmacies-offer-service/

Contraceptive Technology

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This month’s clinical pearl

December 2018 Clinical Fact:

“Because implants and IUDs are highly effective, they are excellent choices for the short-term, too, and the fact that an implant or an IUD is good for “up to” 3 to 20 years is an added advantage but not always relevant.” — Contraceptive Technology, 21st edition